Sunday, August 30, 2020

Why Don’t the Dutch Wear Covid Masks?


Vlog

This post is available as a vlog. Why? Just trying to serve you better! Perhaps you just got back from the eye doctor and your pupils are dilated, so it’s really hard to read the screen text. In that case, just roll the video, kick back, gaze at the blurry talking head—or not!—and let the audio monologue wash over you, leaving you deeply edified, catatonic, or both! (For the regular text version just scroll down. Obviously.)


Introduction

I was surprised to learn recently that the Dutch government not only doesn’t require face masks to stop the spread of the coronavirus, but formally opposes masks, telling people that they don’t help and might even hurt. I decided to delve into this and learn more about it—not just by reading up on the subject, but by sending a survey to both Dutch and American citizens, to compare the results. In the process I have, surprisingly enough, hit upon a novel way forward that could really help.

What the Dutch government says about masks

According to this article in the British Daily Mail, Coen Berends,  spokesman for the Dutch National Institute for Public Health and the Environment, stated, “Face masks in public places are not necessary, based on all the current evidence. There is no benefit and there may even be negative impact.”

(Based on all the current evidence? Like, every study worldwide? Really? This post isn’t primarily focused on the effectiveness of masks, but for more on this question see the appendix.)

The article goes on to say, “Christian Hoebe, a professor of infectious diseases in Maastricht … [and] head of infectious disease control in Zuid-Limburg, the region hit hardest when the pandemic struck Holland, pointed to a Norwegian study showing 200,000 people must wear surgical masks for one week to stop a single Covid-19 case.”

Okay, I’m just going to stop right here and cry bullshit on the Norwegian study. It fails the sanity test. Meanwhile, basing Dutch policy on a Norwegian study seems a bit flimsy now, considering that the government of Norway, two weeks ago, revised their own position on masks. According to this article, “the ministry recommends face masks as an extra precaution when it is difficult to maintain a ‘social distance’ of one meter or more on public transportation.” Granted, this is still a far cry from a nationwide mandate, but if the Norwegian government really believed 200,000 people must mask up for a week to stop one case, they wouldn’t have made this recommendation. The researchers who came up with that 200K figure are, in strict epidemiological terms, whacked out on coke and smack.  (I note that Holland already mandates masks on public transit.)

Setting aside the Norwegian article, let’s dig in to the Dutch government’s assertion that there’s no benefit and there could be possible negative impact. According to this Reuters article, “RIVM chief Jaap van Dissel … argued wearing masks incorrectly, together with worse adherence to social distancing rules, could increase the risk of transmitting the disease. ‘So we think that if you’re going to use masks (in a public setting) ... then you must give good training for it,’ he said.”

Okay, so here’s a novel idea: how about simply providing that training? How hard could it be? After all, the Dutch have done a great job teaching contraception. As described here, they have the lowest abortion rate in Europe. I think van Dissel’s lack of faith here seems unreasonably defeatist.

And how about empirically investigating the relationship between mask wearing and social distancing? Turns out, a study has done just this. As detailed here, “A group of researchers observed people walking the streets of the Dutch capital and found that wearing masks did not give anyone a false sense of security … As part of the research, Lindegaard analysed video footage from June 1 of a shopping street in Amsterdam that was not particularly overcrowded. The footage showed that people wearing a mask violated the 1,5 metre distance rule just as frequently as people not wearing masks. Her research also found that 80 percent of those wearing masks wore them correctly.”

(Note that this fellow here is French, not Dutch.)


How do the Dutch people feel about masks?

Masks are frankly a pain in the ass, so it’s not surprising that crack investigative journalism turned up some decidedly anti-mask attitudes. The Daily Mail article reported that the Dutch government’s policy has brought about “the delight of all the citizens I spoke with in Amsterdam. ‘I hate wearing them,’ said Aicha Meziati, 29, in the hip fashion store Das Werk Haus. ‘They are horrible. People look like they have nappies on their faces.’”

(Since most of my audience is American, I’ll point out here that a) a “nappy” is a diaper, and b) both paper and cloth masks can resemble diapers. Probably few Americans have ever seen a cloth diaper, but trust me, they look a whole lot like white cloth face masks, like the ones my employer mailed me.)

Notwithstanding the retail employee’s pithy statement (which, by the way, showcases a rather naïve attitude toward the seriousness of this pandemic), the Mail goes on to say that “two recent polls claim a majority [of Dutch citizens] back use of face masks for indoor public spaces.” The Mail doesn’t cite either poll, but I found this article that states, “In a weekly poll conducted by political researcher Maurice de Hond, 55 percent of the [Dutch] people surveyed revealed they think face masks should be made compulsory in order to help battle a second wave of the coronavirus.”

I wouldn’t put too much stock in any one survey, but I’ll bet there are more Dutch citizens who support a mask mandate in the abstract than there are Dutch citizens who actually wear masks. It’s human nature to go with the flow and not be that odd person taking a precaution that nobody else is. If I somehow found myself in Holland right now, I’d be more conflicted about going outside with a mask on than I am in the U.S., because I wouldn’t want anyone construing my behavior as a silent judgment against theirs.

Now let’s get to my survey results, and the thoughtful comments from my Dutch respondents, whose direct personal experience can nicely supplement the stuff I’ve read online.

The survey responses

I’ll have to start out by saying my survey was not very broad … only three Dutch citizens responded. I’m only one guy and the research budget for albertnet is zero. Still, I hope you’ll agree three bits of anecdotal evidence are better than nothing. (If you don’t, click here.)

Of the three Dutch respondents to my poll, none wears a mask. Two of these respondents, asked why not, chose the answer, “I’m not sure the Dutch government is right about masks but I don’t wear one because if I did, I would stand out.”

The third respondent chose the answer “I agree with the Dutch government that masks aren’t helpful so I don’t wear one,” with this added comment: “While I answered no, I do think masks would be useful if they: - Are quality masks - Are switched regularly (never worn consecutively) - Are actually worn over the mouth and nose. However as is the case, the quality masks that make a difference are reserved for healthcare workers. This leaves the rest to wear masks that don’t really work.” So this is a bit different than saying masks couldn’t help.

Asked if the Dutch government should require masks, one Dutch respondent answered yes, “Because it makes it more visible that Covid is present. Makes people more aware that they have to keep distance.” The two others could  not decide. One of these two says, “I think it’ll cause too much protest” and the other says “if it was made easier (or cheaper) to get quality masks, and everyone does it correctly, I would make it mandatory.”

Holland vs. U.S.

I’m not going to compare overall Covid rates between the US and Holland, nor compare the efficacy of our governments, other than to say when I mentioned the Dutch government’s position to my daughter, she replied, “I love that we’re not the only idiots!”

What I want to explore is how consensus in a community can be a very comforting thing, especially during such difficult times. I mentioned already that in the absence of a mandate the Dutch people will tend to behave the same—that is, not wear masks.

Happily, I don’t have to worry about offending anyone in my community when I wear a mask. Of the 19 American respondents (all of whom are on my bike club, and are thus local), 17 believe masks help, and two chose “I really don’t know.” Regarding a nationwide mask mandate, 15 support it, three can’t decide, and only one opposes it. My American respondents’ comments tended to be about wide open spaces and the need to address regional differences but with consistent, national thresholds applied.

Suffice to say we’re all on the same page in my neighborhood. Contrast this to other parts of the U.S. where you can be hassled for wearing a mask, or for not wearing one, depending on your neighborhood and/or whom you happen to encounter. At least in California we have a statewide mandate, so wearing a mask doesn’t make much of a statement (other than “I don’t want to get in trouble with the law”). Nobody can differentiate between the “us” who only wear a mask because they’re required to, and the “them” who really believe masks are helpful (or vice-versa if you’re on the other side of the fence). So you have widespread adoption of a behavior that reduces the spread of the coronavirus, without all the social friction. I would love to see this be adopted nationwide, and I think this would help in the Netherlands as well. Anywhere, really.

Can the Dutch government change their tune?

Initially, the CDC in the U.S., along with the World Health Organization, discouraged the use of masks, but as more data have become available, both agencies have changed their position. Is it realistic to assume the Netherlands may eventually fall in line?

Well, it could be tricky politically. This Dutch News article points out, “Last week microbiologist and epidemiologist Amrish Baidjoe wrote an open letter to the cabinet urging ministers to back the wearing of masks indoors. He accused [RIVM Chief] Van Dissel and prime minister Mark Rutte of being worried about the damage to their image if they changed their mind. ‘They have been saying masks do not work for too long, and that makes it difficult to change,’ he said. ‘It is part of a trend of being far too definitive in communication about things which are not so certain.’”

It could be that this accusation is unfair, and/or the supposed fear of political embarrassment is unfounded. My (albeit tiny) survey suggests this. I asked how my Dutch respondents would feel if the government changed their minds and started requiring masks in public. Two chose the reply “I would be relieved because I think we’d be safer with a mask requirement” and the third chose “None of the above” and commented, “I would be annoyed because masks are annoying. However, if they made it mandatory they probably did it based on scientific research. This would make me relieved because that means there is a safer way to go out in public. If they did it without any reason I would pick option 3 [less respect for Dutch government].” Fair enough.

I asked specifically if the Dutch respondents would lose respect for their government simply for abandoning their initial position (i.e., for being wishy-washy). Two responded that “This wouldn’t affect my opinion of the Dutch government” and one added, “I like that the government bases the decisions on science and follows what the RIVM says about it. I realize new studies can show new things and I trust the RIVM in evaluating what studies are trustable.” The third respondent chose the response, “I would have more respect for Dutch government because they can admit when they’re wrong.”

Is there a quick fix?

Unfortunately, to get the Dutch government to change their position would require that new evidence be put in front of them, or that they take another look at existing studies … both of which would take precious time, while the rate of infection is climbing. Is there another, faster way forward?

There is! We don’t actually need to persuade the Dutch government that masks prevent airborne transmission of the coronavirus … we just need to give them other reasons why masks should be worn. I have come up with three very compelling ones.

First, if aligned with a powerful campaign of public service announcements, a mask mandate could increase social distancing behaviors. The key is to focus on a particular side effect of prolonged mask wearing: maskne. This is the problem of mask-induced acne, and as detailed here, it’s a real enough problem that “the Covid-19 task force of the American Academy of Dermatology (A.A.D.) felt compelled to release advice on the subject.” So, if a nation is required to wear masks in public, and masks cause maskne, what is the natural human reaction? To stay home! And that’s exactly what needs to happen. Too many people are going out there on stupid, needless errands just because they’re bored of being housebound. Well, boo hoo hoo … people are dying! If you hired a bold filmmaker like Lars von Trier to create an absolutely grotesque and graphic PSA video of mask-induced acne, with a tagline like “Maskne is not worth it … please just stay home,” the good people of Holland might do just that.

Next, we need to point out to the Dutch government a simple fact that so often goes unappreciated: masks can be very, very sexy. Just look at how beautiful and mysterious this woman looks:


The fact is, even if not all people are beautiful, almost everybody has pretty eyes. Alas, so often the effect of nice eyes is ruined by nose hair, unkempt beards, cigarette-stained teeth, or a weak chin. A mask easily hides these shortcomings. The trick is to furnish the Dutch people with elegant masks that actually enhance their appearance. It would be a pity if somebody spoiled the effect with an ill-advised design like one of these:



Finally, we need to impress upon the Dutch government that the pandemic is not the only global crisis right now: there’s also the economic turmoil that Covid-19 has wrought. It’s time to get businesses back on their feet, and masks can be a big part of that. How? One word: advertising. These pro cycling teams have the right idea:




If the Dutch government suddenly mandated the wearing of masks when in public, for these reasons alone and irrespective of masks’ efficacy in reducing airborne spread of the coronavirus, they could slow the spread of COVID-19 and eventually look like heroes to the Dutch people.

Appendix – Should we believe that masks help?

This study “provides evidence from a natural experiment on the effects of state government mandates for face mask use in public issued by fifteen states plus Washington, D.C., between April 8 and May 15, 2020 … Mandating face mask use in public is associated with a decline in the daily COVID-19 growth rate by 0.9, 1.1, 1.4, 1.7, and 2.0 percentage points in 1–5, 6–10, 11–15, 16–20, and 21 or more days after state face mask orders were signed, respectively. Estimates suggest that as a result of the implementation of these mandates, more than 200,000 COVID-19 cases were averted by May 22, 2020.”

Meanwhile, this publication declares, “In countries with cultural norms or government policies supporting public mask-wearing, per-capita coronavirus mortality increased on average by just 8.0% each week, as compared with 54% each week in remaining countries.”

The University of California at San Francisco (UCSF) medical school is very highly respected, and I have all too much firsthand experience with their hospitals and medical centers, all of it positive. They published this very compelling article explaining why masks are helpful, and how the CDC and WHO came to reverse their earlier positions. Among other evidence, the article cites case studies from UC San Francisco epidemiologist George Rutherford, MD and infectious disease specialist Peter Chin-Hong, MD: “In one case, a man flew from China to Toronto and subsequently tested positive for COVID-19. He had a dry cough and wore a mask on the flight, and all 25 people closest to him on the flight tested negative for COVID-19. In another case, in late May, two hair stylists in Missouri had close contact with 140 clients while sick with COVID-19. Everyone wore a mask and none of the clients tested positive.”

Of course, you don’t need to believe any of this to support a worldwide mask mandate. The Netherlands should impose one for the indisputable social value of masks: their sex appeal, the advertising space, and the maskne-driven increase in improved shelter-in-place behaviors.

More reading on the pandemic 
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